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He said after speaking to Black, he had no concerns about the prisoner's welfare.

The inquiry heard a form called ACT, now called Talk to me, for prisoners who are reportedly feeling suicidal, should have been filled in after Black returned to prison from hospital in December 2016 and that is now then new protocol for staff.

Although Mr Easton confirmed that as part of that procedure a prisoner would be put on 15 minute observations which Black had anyway, because he had returned to prison out of hours he was unable to be seen by a doctor until the next day.

Mr Easton was asked about the incident weeks later and recalled arriving at work around 8.10am on January 15 when he received a call and went to straight to Black’s cell.

He said by the time they got there, staff had done all they could to save Black, but nothing could be done.

Dr Daly said in evidence he spoke with and examined Black after his release from hospital in December 2016.

He said Black denied taking any illegal drugs and noted “patient did not seem especially interested” in what the doctor had to say about the dangers of drugs.